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Henry County Public Schools Health Services

Primary Care Provider Authorization: DIABETES

Student Name: ______Date of birth: ______

School: ______School year: ______

[ ] Car rider [ ] Bus rider (provide bus number(s) ) ______

Diagnosis: [ ] Type I Diabetes [ ] Type II Diabetes

[ ] Insulin resistance ______

Blood glucose monitoring:

  • Target range for blood glucose: ______mg/dl to ______mg/dl
  • Student can perform own blood glucose testing?[ ] Yes [ ] No ______
  • When should monitoring be done? [ ] As needed to determine hypoglycemia or hyperglycemia [ ] Before meals[ ] Other ______

MEDICATIONS:
  • Does this child require insulin during school hours? [ ] Yes [ ] NoIf “yes”, insulin type? ______
Carbohydrate ration for food: 1 unit for every ______grams of carbohydratesprior to breakfast
1 unit for every ______grams of carbohydrates prior to lunch
1 unit for every ______grams of carbohydrates prior to snacks
Student can calculate carbohydrate count for meals and snacks independently? [ ] YES [ ] NO______
Student can calculate and administer insulin independently? [ ] YES [ ] NO ______
High blood glucose correction: : 1 unit for every _____mg/dl above correction target of _____mg/dl
Give only with scheduled meals unless otherwise noted: ______
For students with insulin pumps:
Type of pump: ______Basal rates: ______
Insulin/carbohydrate ratio: ______Correction factor: ______
Is student competent regarding pump?[ ] Yes[ ] No ______
Can student effectively troubleshoot problems (e.g., ketosis, pump malfunction)? [ ] Yes [ ] No ______
KETONES: Check ketones for BSL >= ______and notify parent(s)
Give additional insulin as follows for KETONES: Small _____units, Moderate _____units, Large _____units
Where are the following supplies kept? Glucometer/testing supplies:______Ketone strips: ______Insulin: ______Glucagon: ______Snacks:______
Exercise and sports:
  • Student should not exercise if his/her blood glucose level is below ______mg/dl or above ______mg/dl
  • Are there other restrictions related to sports/exercise? [ ] Yes [ ] No Explain: ______

Meals/Snacks:
Diet: [ ] No concentrated sweets [ ] Carbohydrate counting
Snack before exercise?[ ] Yes [ ] No ______Snack after exercise?[ ] Yes [ ] No ______
Other times to give snacks (include content & amount): ______
  • Does student have special needs for class parties? [ ] Yes [ ] No ______
Additional guidelines: ______

Hypoglycemia (low blood sugar)

Signs and symptomsmay include any of the following: *hunger * mood changes *irritability *crying *confusion *headache *inappropriate responses *shaky, nervous *dizziness/blurred vision *drowsiness/fatigue *loss of consciousness *restlessness *combativeness *numbness, tingling lips/tongue *pounding heart *unusually pale, moist, or clammy skin

IF BLOOD SUGAR IS ______OR LOWER STAFF WILL PROVIDE THE FOLLOWING INTERVENTIONS:

**If at meal time, hold insulin until after the meal or snack**

  • Give 15 grams of simple sugar (examples include):

* ½ cup (4oz) regular soft drink * 15 skittles *1 small tube of cake icing gel * ½ cup (4ox) juice *12 sweet tart * 3-5 small sugar cubes * 3-4 glucose tablets * 2-3 rolls of Smarties * 2-3 packs of table sugar

  • Follow immediately with a 15 gram complex carbohydrate snack or lunch (examples include):

* 4 peanut butter or cheese crackers * ½ sandwich*1 small bag of pretzels

  • If no improvement within 15 minutes, give another simple sugar choice from above
  • Have student check his/her blood glucose 30 minutes after treatment started. Allow 30-60 minutes for full recovery before resuming normal school activity. It is not necessary to send the student home once the BSL reaches >=80.
  • If blood sugar remains low after the above steps, notify parent/guardian.

Hyperglycemia (High blood sugar)

Signs and symptomsmay include any of the following: * increased hunger *extreme thirst *increased urination

*dry, itchy skin * nausea *drowsiness/sleepiness *dry mouth *headache *other______

IF BLOOD SUGAR IS ______OR HIGHER STAFF WILL PROVIDE THE FOLLOWING INTERVENTIONS:

  • Encourage extra liquids without sugar, such as water. NO juice or milk
  • Check ketones and allow frequent restroom breaks as needed
  • Notify parents if ketones are positive
  • Student does not need to be sent home unless vomiting, ketones are positive or other acute illness
  • Additional guidelines ______

**EMERGENCY PLAN OF ACTION**

  1. If student becomes unconscious or unresponsive administer GLUCAGON 1mg (1cc=100u) into the muscular area of the upper arm (kit to be provided by parent)

Glucagon to be kept: [ ] With student at all times [ ] In the school office [ ] Other ______

*If glucagon needs to be available on the bus, parent’s must provide extra glucagon if student is not allowed to carry*

  1. Notify school emergency response team/school nurse and initiate CPR for absence of pulse/respirations.
  2. Call EMS and parent/guardian

Printed name and address of physician: ______

Physician signature: ______Date: ______

Telephone: ______Fax: ______

**Note to parent: Signing this form shall release Henry County Public Schools and staff from liability of any nature that might result from actions directly related to this plan of care. I understand that I have the ultimate responsibility for providing the school and the physician with updated medical information that may affect my child’s plan of care and providing adequate medication and supplies.

Printed name of parent/guardian: ______

Signature of parent/guardian: ______Date: ______

Please complete this form and return to:

Henry County Public Schools, Health Services

Melissa S. Jeffries, RN, BSN

326 South Main Street, New Castle, KY 40050

Telephone: (502) 845-8600 Fax: (502) 845-8601